Policy, Research, and External Affairs
WORKING PAPERS
Population, Health, and Nutrition
Population and Human Resources Department
and the Health Services Department
The World Bank
August 1991
WPS 740
The Onchocerciasis
Control Program
in West Africa
A Long-term Commitment
to Success
Bernard H. Liese
John Wilson
Bruce Benton
and
Douglas Marr
Among African health programs, this program to control
"riverblindness" is an exceptional recent success story. Here are
some lessons from it.
The Policy, Research, and Extemal Affairs Complex disu ibutcs PRI Working Papers to disseminate the findings of work in progress and
to encourage uhe exchange of ideas among flank staff and dll othcrs interested in developenent issues. lhese papers carry the names of
the authors, reflect only their views, and should be used and cited accordingly. The findings, interpretations, and conclusions are the
authors' own. They should not be attributed to the World Bank, its Board of Directors, its management, or any of its member coutitries.
Policy, Research, and External Affairs
Population, Health, and Nutrition
WPS 740
This paper- a joint product of the Population, Health, and Nutrition Division, Population, Health, and
Human Resources Department and the Health Services Department - is part of a larger study undertaken
in PRE of African Health Policy. Copies are available free from the World Bank, 1818 H Street NW,
Washington DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (14 pages).
Onchocerciasis is a devastating African The main challenges of the program have
parasitical disease that causes sevcre debilitation been to combat the reinvasion of controlled areas
and intense itching. By the time its victims are by blackflies, to manage multiple resistance to
in their late twenties, they experienec impaired the larvicides that were used, avoiding any
vision, often blindness. River villages are negative impact on the environment, to develop a
particularly afflicted because the blackflies drug that would kill the parasites, and to hand
which transriit the worm parasite that causes the control of residual responsibilities over to the
disease breed in rivers - hence the colloquial beneficiary countries once the program ends.
"riverblindness."
Liese and his collcagues identify the main
The connection between life by the river and reasons for the program's success as:
blinding onchocerciasis lcd to the virtual aban-
donment of many fertilc river valleys, so poten- Limited, achievable, clearly defined objec-
tially productive lands lay idle for many years. tives and a realistic 20-year timeframe. The
Yet millions continued to succumb to the disease request for a 20-year commitment did not meet
until the onchocerciasis control program, a large with potential donors' immediate approval, but
multidonor-supported effort initiated in 1973 ar the proponents of the program remained firm in
the instigation of Robeit McNamara, then head their assessment that this much time was neces-
of the World Bank. sary to eliminate the parasite reservoir in the
human population.
Today, 95 percent of the original seven- e Use of the best technology available for any
country area is virtually free of the disease, and task.
previously deserted lands are being resettled and e Contracting out highly specialized tasks
cultivated, increasing agricultural production. such as aerial spraying.
* Operationai r> .:arch (considered an equal
From the beginning, the program maintained partner in progratn implementation).
a limited, specific objective: to control * Program autonomy, which allowed flexibil-
onchocerciasis in a clearly delineated area in the ity in responding to strategic and technological
savannah zones of West Africa. The operational issues.
focus was to interrupt transmission of the disease - Delegation of authority to those most
and eventually eliminate the parasitc in all the closely involved in the program, thus assuring a
human population. The only acceptable ap- clear focus and flexibility.
proach was effcctive control of the disease- e Long-range planning to sustain donor
transmitting blackfly. The strategy was to focus commitment.
on destroying blackily larvae located in fast- e Transparency, made possible by a compre-
flowing rivers, which could easily be targeted hensive flow of information and the program's
with aerial spraying. openness to evaluation and review.
The PRE Working Paper Serics disseminates thc findings of work under way in thc Bank's Policy, Rescarch, and Extcmal
AffairsComplcx. An objectivc of thc series is to gct these findingsout quickly, even if presentations are Icss than fully polished.
Thec findings, interpretations, and conclisions in these papers do not necessarily reprcsent official Bank policy.
Produced by the PRE Dissemination Center
THE ONCHOCERCIASIS CONTROL PROGRAM IN WEST AFRICA:
A LONG-TERK COMMITMENT TO SUCCESS
Bernhard H. Liese, John WlIson, Bruce Benton and Douglas Marr
1. Development of health systems in West Africa has been fraught with
difficulties for many years and most health services still fall far short of
meeting basic needs. In most West African nations the paucity of human and
financial resources, management capability, and political will has made
lasting improvements difficult to achieve even when financlal support from aid
agencies such as the World Bank has been readily available. Some programs,
however, have met with sttccess despite these constraints. These are, in
particular, programs which have been focused on one disease or a group of
diseases. The Smallpox Eradication Program has been the classic example and
the Expanded Program of Immunization has had a significant impact on five
major diseases affecting children. The most notable recent example, however,
is the Onchocerciasis Control Program (OCP) in West Africa. The OCP is
recognized as a solid pillar of achievement among health development efforts
and is considered by the donor community the most successful health program in
West Africa. This paper reviews the OCP's experience with the objective of
drawing more general lessons for the Bank's health and development work.
2. Onchocerciasis has long been the cau e of great human suffering across a
wide part of Africa stretching westward from the Sudan to Senegal and
southward to Malawi. Although not confined to it, the disease is most
devastating in the drier sudan and guinea-savannah areas and is caused by a
thread-like worm, gngh2ceygA ygbMIj, which is spread by the bite of female
blackflies (Sitiultua daMo s.l.).1 Victims of onchocerciasis experience
severe debilitation and itching due to the proliferation of millions of infant
worms produced by adult worms located in unsightly nodules under the skin. By
the time victims are in their late twenties and have been repeatedly infected
by the parasite, the result is impaired vision and often blindness. Although
it is not a killer disease, onclhocerciasis appears to reduce life expeftancy
and threatens the viability and very existence of entire communities. Since
the blackflies which spread onchocerciasis breed in rivers, those villages
located close to them are the most severely afflicted; hence the colloquial
term nriverblindnessv.
1Some of the several varieties of SimulLu dMo s.l. are more effective
vectors than others. The species complex is divided into forest forms (f.
soubreng , E.. mncetigauli and E. Y1bQnsu), savannah forms (a. sirbansa and S.
gE2JUX s.s.) and an intermediate variety E. msuamosum. Control efforts
concentrate on the savannah forms and E. louaRwsum since the forest forms do not
appear to be responsible for blinding onchocerciasis.
2
conomic Impact
3. The connection becween life by the river and blinding onchocerciasis led
to the virtual abandonment of many fertile river valleys. People crowded on
to marginally productive lands plagued by over-farming, desertification and
drought, while potentially productive lands have lain idle for many years. As
transmission of the disease is possible anywhere within the very extensive
flight range of the blackfly vector, moving out of these river valleys has not
guaranteed protection from onchocerciasis; millions were still infected by the
parasite. Many who would otherwise be at the peak of their productive lives
found themselves unable to contribute adequately to the support of their
families. Extended famalies or other villagers were forced to provide for
those disabled by the disease. In the never-changing situation, new victims
succumb to blindness and take the place of those who died, so maintaining the
burden of this disease on the commun 4y.
History of the Progrm
4. In the 1960s, the French scientific research organization, ORSTOM,
operating in conjunction with the Organization de Cooperation et Coordination
des Grandes Endemies (OCCGE), collected a large amount of data on
onchocerciasis and the blackfly vector in western Burkina Faso, northern C6te
d'Ivoire, and Mali. The World Health Organization (WHO), in an inter-country
project supported by the United Nations Development Program (UNDP), gathered
similar data from northern Ghana, eastern Burkina Faso and northern Togo.
These studies confirmed that the Volta River Basin in West Africa was the
largest contiguous focus of onchocerciasis in Africa and documented the
devastating effect of onchocerciasis on the region's population and economy.
5. Following the positive outcome of a conference in 1968 deeming the
control of onchocerciasis feasible, seven West African Governments--Benin,
Burkina Faso, COte d'Ivoire, Ghana, Mali, Niger, and Togo--requested, in 1969,
WHO assistance in formulating the terms and conditions of an onchocerciasis
control program. They clearly recognized that onchocerciasis was a major
health problem in their savannah areas and that the disease was wreaking havoc
among their rural populations who were debilitated, blinded and forced to
abandon fertile river valleys. The governments of these countries were keenly
aware that the blackfly vector did not respect political boundaries, and that
independent national effort could not control onchocerciasis effectively. The
costs and implications would exceed the capabilities of any one government and
intercountry collaboration and donor assistance would be necessary.
6. In 1970, UNDP provided funding for a Pre-Asslstance to Governments (PAG)
Miusion to the above seven countries, the report of which was presented to a
meeting of potential donors in Paris in December 1973. The report concluded
that effective onchocerciasis control could be achieve in savannah zones only
if its endemic area were clearly delineated and if such control were intensive
and sustained cnerein long enough to kill off the indigenous parasite. The
PAG Mission report thus identified an area of 640,000 km2 incorporating 18,000
km of rivers, to be kept under control for 20 years at an estimated cost of
US$120 million (at 1973 dollar value). Nine donors and agencies--Canada,
France, the Federal Republic of Germany, Netherlands, the United Kingdom, the
3
United States of America, UNDP, the World Bank, and WHO then pledged their
commitment to the Onchocerciasis Control Program which was launched in January
1974.
7. The Bank has played a vital role in the Implementation of the OCP from
the outset. Its participation began in 1972 when Robert McNamara, then
President of the World Bank, visited West Africa and was so concerned about
the dreadful impact of onchocerciasis on entire communities that he promptly
convened a meeting in London with the heads of UNDP, the Food and Agricultural
Organization (FAO), and WHO to consider what might be done wlth regard to the
control of the disease and the subsequent development of the river valleys.
A Steering Committee was consequently established in 1973, composed of
representatives from each of the above agencies, whose mandate was to guide
the development of a program. The Steering Committee gave support to the PAG
Mission and helped to establish the structure of the program. The Bank also
made an important contribution to strengthening the management of the program,
in its early years, by seconding one of its senicr staff to assume the
position of Director of OCP for a period of three years.
8. Since then, the OCP has doubled its 'perational area to cover 1.3
million km2 and 50,000 km of rivers. It has incorporated four more countries:
Guinea, Guinea Bissau, Senegal and Sierra Leone; and it has attracted a
further 15 donors: the African Development Bank, Belgium, the European
Economic Community, Finland, the Gulbenkian Foundation, Italy, Japan, the
Republic of Korea, Kuwait, Luxembourg, Norway, the OPEC Fund for International
Development, Portugal, Saudi Arabia, and Switzerland, to support an annual
budget of approximately US$30 million. Complete operational coverage of this
enlarged program area was achieved in 1990.
9. Today the program is an acknowledged success. Ninety percent of the
original area Is virtually free of onchocerciasis. The population is no
longer debilitated from the disease. To date blindness has been prevented in
over 100,000 people, and 9 million children born in the area since 1974 are no
longer at zisk of contracting the disease. Vector control activities
throughout 90% of the original area have been halted since the risk of
recrudescence of onchocerciasis is now negligible. Moreover, fertile river
valleys have been opened up for socioeconomic development and new communities
are being established along rivers where previously people would have been
exposed to the worst ravages of the disease. National governments can now
confidently promote farming and agroindustry in these areas, supplanting
dependency with surplus production. Already, previously deserted lands are
the site of thriving plantations producing sugar, tea, cotton, rice and other
food and export crops.
The OnchocSerLcas COntrol StrEAteg
10. From the beginning, the program has maLntained a limited and specific
objective: to control onchocerciasis in a clearly delineated area in the
savannah zones of West Africa. This objective was initially linked to the
socioeconomic development of the area and, later, to the development of the
capability in the health sector in each of the Participating Countries to
maintain onchocerciasis control. However, these considerations have not been
4
allowed to detract from the principal goal of the program to achieve
onchocerciasis control.
11. In the absence of a suitable drug or vaccine, the operational focus of
the OCP has been to interrupt onchocerciasis transmission leading to the
eventual elimination of the parasite. The PAG mission report confirmed that
the only acceptable approach was the effective control of the blackflies that
transmit the disease. With a flight range that exceeds 300 km, the adult
blackflies disperse too widely and are ntot targetable. As a result, the
strategy has of necessity focused on blackfly larvae whose locations are
identifiable. The blackfly breeding sltes are not hard to find since the
females deposit eggs only in fast-flowing parts of rivers and streams. For
the 8-to-10-day period when the larvae are developing in the water, they can
be killed by larvicide. The weekly application of larvicide upstream of
breeding sites2 has been the basic control strategy of the OCP and it has
remained unchanged since the program began.
12. Because of the length of river (between 5,000-30,000 miles) which has to
be covered on a weekly basis and the inabilit' to reach all the breeding sites
during all seasons by road, grcund treatment has proven inadequate and
ineffective against 1. 4&=sum. The program has, therefore, had t^- employ
aircraft to obtain the necessary coverage. This is often dangerous, since
many of the targets are along winding and narrow watercourses, and both
helicopters and fixed wing aircraft with highly skilled p'lIots must be used.
The aerial spraying has therefore been contracted out to private, specialized
firms. This singular method of vector control is the most cost-effective
technology for OCP. One helicopter can do in one hour what a highly trained
ground application team could not achieve in a week. The operations are
sophisticated, currently engaging up to 11 helicopters and two fixed wing
aircraft, and require a high degree of coordination between the aerial
spraying team and the program staff who determine when, where and how much the
pilots are to spray. This coordination of larviciding activities is the
responsibility of OCP. Deployment of the aircraft depends on the weekly
collection and anvlysis of data on the quantity and location of breeding
sites, on water levels and water discharge (which affect the quantities of
larvicide to be applied), and on the effectiveness of the previous week's
application of larvicide. The program must ensure that the fuel and pesticide
depots are regularly replenished throughout the program area. It must also
monitor the size of the biting blackfly population, and periodically measure
the level of infection in the human population.
13. The lifeline of the system is a radio network. This network links the
information-gathering field offices throughout the program area to the two
operations centers--in Bamako, Mali in the west and in Kara, Togo in the east
2 The blackfly eggs are deposited on to stems and rocks just below the water
surface; within two days they hatch and the larvae again attach to substrates
in the water. The larvae filter small particles from the water that pass through
their digestive system. At this stage, any larvicide particles introduced into
the stream are trapped in the filter fans and pass into the gut killing the
larvae.
5
--which deploy the aerial spraying fleet. The radio network also enables the
Program Headquarters in Ouagadougou, Burkina Faso, to maintain contact with
all aspects of operations. The location of targets for spraying is determined
by mobile toams supervised by entomologists which capture t' e blackflies for
analysis of their numbers and their potential to transmit onchocerciasis.
This information, together with water levels taken in river gorges, is relayed
by radio from subsector to sector offices and from there to the operations
centers where the maps to guide the pilots in their weekly circuit of spraying
are prepared.
14. Measurement of the impact of blackfly control on onchocerciasis in the
village populations is carried out by three medical and ophthalmological teams
which monitor the level of infection in a large sample of communities
throughout the program area. A sample of villages is visited on rotation
every three years to plot the change in disease patterns over time. This
indicates when populations are or will be free of the disease or if there are
some impediments to progress.
The Program Structure
15. Becaase of their inability to undertake effective control of
onchocerciasis on a national level, the Participating Governments, through
signed Memoranda of Agreement, gave OCP the mandate to carry out the control
operations throughout the delineated area on their behalf.
16. The OCP was formally set up with its own independent structure with WHO
as executing agency, and the Bank as fiscal agency responsible for all fund-
raising. However, the governing body of the OCP is the Joint Program
Committee (JPC) comprised of representatives from the Participating Countries,
the Sponsoring Agencies, and the donors. The JPC, which has its own terms of
reference approved by all members including the Bank and WHO, ensures the
implementation of OCP policy and approves budgets. A critical feature of tne
JPC is its functional independence from WHO and WHO's governing bodies, i.e.
the World Health Assembly and the WHO Executive Board; it is thus not
distracted or influenced by the political priorities of WHO. This was
particularly important in the early years of the program when OCP's vertical
approach towards combatting a single disease was at divergence with WHO's
multivalent primary health care policy.
17. The day-to-day steering and coordination of the OCP is delegated by the
JPC to the Committee of Sponsoring Agencies (CSA) (the successor to the
Steering Committee) which meets several times during the year. Within the
CSA, the principal actors are the World Bank and WHO because of the critical
roles they play in the program's implementation as fiscal and executing
agencies, respectively. It is the CSA which actually follows the program most
closely, guiding policy development, reviewing plans and programs, maintaining
short-term financial control, and monitoring overall implementation of the
program between annual sessions of the JPC. The OCP Director, therefore, has
several opportunities during the year to report on the program and to seek
guidance in resolving operational or financial problems. Also, problem
solving and preparation for CSt. meetings has been facilitated by regular
contact and flow of information between the Program Director's liaison officer
6
in Geneva, who is also the Secretary of the CSA, and the Bank's representative
In Washington, D.C.
18. As Executing Ageney for the Program, WHO carries out the action plans
and strategiea approved by the JPC. WHU, in consultation with the CSA,
appoints the OCP Program Director who reports dlrectly to the JPC. Having
been delegated full responslbility for OCP by the Director General of WHO, he
has relative freedom and independence of action within WHO on matters
pertainLng to the program. WHO itself provides technical, administrative and
legal assistance ln such areas as larvLcide development and selection, drug
screening, hiring and procurement. As the Flscal Agent for the program, the
World Bank manages the Onchocerciasis Trust Fund, which constitutes all donor
contributions, and disburses OCP funds on a quarterly basis through WHO. In
addition to contributing from its own account, the World Bank is responsible
for mobilizing financial resources from the donor community. The separation
of executing and fiscal responsibilities is a feature of the program that
deserves special notice. It opened up sources of financing not normally
available to WHO, and most importantly, it avoided conflict between WHO's
regional or global priorities and the needs of the program. In addition, the
fLscal arrangements permitted an ongoing external control on expenditures by
the World Bank as a representative of the donors and as a member of the CSA.
19. The program structure also includes two very lmportant independent
statutory review bodies which report directly to the JPC. First, a twelve-
member Expert Advlsory CommLttee (EAC) audits the scientlfic and technical
aspects of the program. Second, a five-member Ecological Group (EG) monitors
the impact of larvicide used in vector control on the riverine ecology and
advises on the selection of new insecticide products. The members of these
two bodies, whlch meet formally once a year in the program area, are
indlviduals of international repute. They are selected by the CSA and
appointed by WHO for a two-year period without prejudice to re-selection.
Both groups have played a critical role in OCP, since its inception, by
recommending or endorsing important modlfications in program operations.
Their views are highly respected by the JPC in helping that governing body
reach important decisions.
20. Finally, in each of the Participating Countries, a National
Onchocerciasis Committee (NOC) coordinates local OCP activities and provides
practical assistance to field operations. The Participating Countries have
committed to pay up to 1.4% of program expenditures in cash contributions or
to provide the required national staff for the operations in their country.
In the latter case the Participating Governments are forced to be more closely
involved in OCP but full management responsibility is retained by OCP which
provides a salary supplement and per diem to the staff concerned. In
addition, the NOCs have held joint annual meetings that have proven to be an
important and productive forum for discussion of shared problems resulting
from the program's activities and success. Likewise the donors meet
periodically in seminars hosted by the Bank to review matters of common
interest related to the ongoing financlal support to the OCP.
21. The program has been implemented in six-year financial phases, each with
separate projected costs formally approved by the JPC and supported by Fund
7
Agreements signed by the donors. The Memorandum of Agreement incorporated
within the Fund Agreements5 is also signed by the Participating Governments.
In addition, the program prepares annual budgets that must be presented for
approval at the annual meetings of the JPC. By the end of 1989, program
expenditures amounted to US$282 million to which the Bank had contributed
US$28 million through the Special Grant Program.
Major Challentes
22. The successes of OCP have not been achieved without several challenges
having to be met and addressed at different period of its Lmplementation. The
major challenges have been Oreinvasion", resistance to larvicide, monitoring
OCP's environmental impact, the development of a curative drug and the handing
over of maintenarce activities to the Participating Governments
(Odevolutionn).
23. Blackfly Reimgion and-Extension of the Program. From the start,
reinvasion of blackflies emanating from source rivers outsLde the orlginal
program area has presented a problem ln controlled areas. About 10% of the
original program area, primarily along its periphery, was affected in this
way. A significant percentage of these incoming flies carried D. vlvulus
worms and thus reintroduced new infection to the reinvaded area. As the
overall attainment of program objectives was clearly threatened, the only
effective solution was to extend the spraying operations to incorporate the
river sources of these blackflies. In 1978, a minor extension of spraying
into southern COte d'Ivoire had some impact in this regard but a major
extension of spraying was recognized as being necessary and was recommended in
1981 by an Independent Commission that was established to review the program.
Based on OCP studies in southern Ghana, Togo, and Benin and by similar WHO
(and later OCP) studies in Guinea, Guinea Bissau, western Mali, Senegal and
Sierra Leone, the program prepared a Long Term Strategy Paper that
established the cost-effectiveness of extending the program in order to
preserve its achievements. Although approved by the JPC for the third
financial phase beginning in 1986, implementation of spraying operations in
the Western and Southern Extensions was considerably delayed because of a
flare-up of resistance to the key larvicide. The EG, supported by the EAC,
placed an Immediate embargo on any extension to the operational area until the
OCP had at least three back-up larvicides to temephos (the product presently
used), esch of which was operationally viable and environmentally acceptable.
When this condition was met and approval given by the JPC, spraying eventually
started in the Extension areas and full coverage of the total Extension areas
was realized in 1990. This now means that the program's objective throughout
the Western Extension area will be attained only by 2004 when spraying
operations can be safely stopped.
24. Combattlng Blackfly Realstance to Larvicide. Anticipating eventual
development of resistance to temephos, OCP began identification and testing of
3 The institutional provisions and arrangements (including minimum pledges
of financial support) for the execution of the program were contained in the
Onchocerciasis Fund Agreements (1974, 1979, and 1986)
8
alternative larvicides early on In the program. This was undertaken with the
full support and encouragement of the EAC, and a monitoring system for early
detection of resistance was set in place. Resistance to temephos first
emerged in 1980 but was for many years confined to an isolated part of
southern Cate d'Ivoire. Chlorphoxim was then introduced as a replacement, and
then, soon after, came B cellua £1urLEn (n l . H-14). The different
characteristics of ht. H-14, especially in the formulation originally
available, required appropriate modifications to the type of spraying
equipment used. It also required the contracting of a larger helicopter at
considerably increased cost to the program. In 1987, the resistance erupted
and expanded rapidly from C6te d'Ivoire to Mali and to the Western Extension
area where operations were just getting underway. The Ecological Group and
Expert Advisory Committee reviewed the situation and placed their embargo on
further extension of operations. Because of the special formulations required
to treat rivers and achieve maximum blackfly control with minimum
environmental impact, the program intensified its collaboration with the
insecticide industry and its field testing of new products. Chemical
companies responded positively and this collaboration led to improved
formulations of jt. H-14 which could be applied with the aircraft already
available in the fleet and in the identification of new larvicide, including
permethrin and carbosulfan. Today, the OCP uses six comnounds, all approved
by the Expert Advisory Committee and the Ecological Group. These are applied
in a rotational scheme which lessens the risk of blackfly resistance.
25. Monitoring the Environmental IMgact. The program was conceived at a
time when the use of insecticides was highly suspect following the publication
of a number of very critical articles on the use and misuse of DDT. It was
important, therefore, that the OCP, from the outset, ensure that larviciding
would not adversely affect the aquatic fauna and flora. Some donors indicated
their inability to support the program should such protective mechanisms not
be incorporated. Accordingly, an independent Ecological Group (EG) was set up
and was already functioning in 1973, before the program officially began.
Because of its independent nature, this EG has been able to assuage any donor
and international concerns about the environment and to ensure that OCP
continues on an environmentally sensitive path.
26. The EG played a vital role from the start in drawing up protocols for
monitoring the treated rivers and streams. These protocols have formed the
basis for the continued review of the impact of larvicide application. All
data collected are presented to the EG for independent assessment. No new
product can be introduced to the operations without the clearance of the EG.
More recently, with the use of several different larvicides in rotation, the
EG has paid particular attention to possible synergistic effects or any other
interrelationships among the various products used. This independent
ecological oversight has enabled the program to continue larviciding without
adverse ecological impact for over 16 years and thus maintain a clean bill of
environmental health.
27. .=t;herAp_y. The possibility of introducing alternative methods of
control to complement larviciding has always been a desired objective of OCP.
It has been hoped that chemotherapy could someday replace larviciding as the
principal means of control. This depends, however, on the development of an
9
effective macrofilaricide (i.e., a drug that would kill the adult worms in the
human body) suitable for mass treatment. The Independent Commission which
evaluated the program in 1981, recommended greater emphasis be placed on drug
development since it deemed that such a drug was necessary ior the continu i
success of OCP. Subsequently, the Onchocerciasis Chemotherapy Project (OCT)
was set up in 1983. This was necessary as an adjunct to the WHO/UNDP/World
Bank-sponsored Special Program for Research and Training in Tropical Diseases
(TDR) to augment the limited funds it could provide from its budget for this
specific purpose. OCT has collaborated with industry and research
institutions in the testing of thousands of pitential products in the search
for such a drug. To date no acceptable macrofilaricide has been found, but
the efforts of OCT have led to the discovery of ivermectin, an effective,
long-acting microfilaricide, (i.e. it kills off the infant worms in the skin).
28. Ivermectin was a drug developed by Merck, Sharp and Dohbe to treat
parasites in animals. Its effectiveness in humans was establ!.shed through
clinical trials carried out by OCT in collaboration with TDR. While
ivermectin does not kill the adult parasite, and kills only tlhe microfilariae,
it does so without the most unpleasant and distressing side effects of
diethylcarbamazine (DEC), a multidose drug available for years but unsuitable
for mass treatment. As a bonus, ivermectin also inhibits, for reasons unkown,
the production of further microfilariae by the adult female worm for about 12
months.
29. Initially, expectations were high that ivermectin could be used as a
control tool by itself, if adequate, population-wide distribution could be
organized, but field trials have shown that the once-per-year treatment leaves
about 5% microfilariae infection, enough to allow continued transmission of
the disease. While thus not a suitable control tool, ivermectin is most
effective in relieving suffering and preventing blindness caused by the
disease. The program began large-scale ivermectin distribution in heavily
infected villages in the Extension areas which resulted in the above
observations being made in 1988. The drug is being donated by the
manufacturer for as long as it will be required so as to encourage its use.
Although the drug is free, the costs of its distribution and monitoring its
effect are considerable. While presently these are borne by the program in
addition t the larviciding costs, they will eventually have to be transferred
to the national governments. Despite its benefits, ivermectin is not the
final answer to the program's needs and the search for a macrofilarcide
continues.
DLvolution and the Role_go the ParticiRating Countries
30. With complete responsibility for -he control operations vested in OCP,
the Participating Governments have pla,_d a relatively minor role. As a
result there has been no provision within their health systems and in their
overstretched budgets for the establishment of a structure, properly staffed,
equipped and financed, to enable them to take over when OCP is eventually
wound up. This weakness was identified by the Independent Commission as early
as 1981 when, in its report, it flagged the eventual devolution of maintenance
activities to the Participating Countries as an essential prerequisite to the
successful conclusion of the OCP. Since then, devolution has been of major
10
concern of the JPC. It may be defined in terms of preventing onchocerciasis
recrudescence in the program area through two activities: (i) enidemiological
surveillance and (ii) focal treatment with ivermectin or another drug, should
it become available, of new cases when these are identified.
31. For some years, OCP has struggled to put devolution into an operational
framework. Initially, there was no tool (or strategy) available that the
countries could employ on their own shoula there be a recrudescence of the
disease. It also became evident that it made more sense to defer devolution
of responsibility until, through the efforts of OCP, the level of
onchocerciasis became such that the risk of its recrudescence was negligible.
This was necessary since, to be effee.tive, larviciding must be international
in coverage and only the OCP itself was equipped to undertake vector control
operations on such a scale. Now, encouragement is being given to the
countries to develop what is necessary for them to maintain the achievements
of the OCP after the larviciding program ceases and so prevent recrudescence.
The recent introduction of ivermectin has provided the countries with a tool
to treat new cases of the disease. As mentioned above, although ivermectin is
not proven as a control mechanism on its own, properly administered, it should
keep the disease at bay. Seven countries where onchocerciasis is now well
under control, Burkina Faso, Benin, Cote d'lvoire, Ghana, Mali an,-! Niger, and
Togo have thus far prepared first step devolution plans. Technical support
will be provided by the OCP to implement these plans.
32. Meanwhile, to try to overcome this hurdle towards devolution, the OCP
has involved the Participating Country governments in the Western Extension
area in other constructive ways. From the outset all staff engaged in the
OCP, whether national or expatriate, have been employees of WHO. This was
modified in 1986 in the extension countries where staff were seconded to OCP
but received a supplementary payment and per diem from the program. The
national governments in the extension area now provide the personnel necessary
to staff the entomological sector offices and the mobile teams involved in
blackfly surveys. These governments are also participating fully in the
ivermectin distribution program.
Reasons for Success
33. Clearly Defined Obiective and Tiere. The most important lesson
from the OCP experience is that a limited and realistic objective,
unambiguously defined, and shared equally by program staff, beneficiaries,
donors and sponsors, is a precondition for success. Such an objective gives
the program a clear mandate and the legitimacy to pursue it. A mandate of
this nature should not be equated with a narrowly defined operational
strategy. While the OCP, for example, uses larviciding as its principal
control tool, larviciding pex se has never become the program's objective.
Larviciding was never confused with onchocerciasis control. The latter point
is especially important since many other health programs and other targeted
development efforts have confused ends and means -- with poor results.
Malaria control programs, for example, set out to control malaria but soon
became extremely rigid DDT spraying programs which later proved unable to
adapt to changing epidemiological or fiscal conditions.
11
34. The OCP has been guided throughout by technical considerations and not
by political pressures. This was exemplified in 1986 when C8te d'Ivoire made
a strong plea to have the OCP area extended to control onchocerciasis in the
forest area. The EAC examined the situation in 1987 and reported to the JPC
later that year that OCP's mandate was control of the blinding form of
onchocerciasis in the savannah areas and such an extension was not justified.
Despite further pleas by CMte d'Ivoire, the EAC maintained its advice to the
;PC, which enabled the JPC to make a definitive decision not to extend
operations, thus saving the program from both operational and financial
* difficulties. Such single-mindedness of purpose has been a critical dimension
in the successful implementation and day to day management of the program.
35. The OCP and the donors agreed at the beginning of the program on a
realistic timeframe for achievement of program objectives. The request for a
20-year commitment by the donors was unprecedented and did not meet with the
immediate approval of potential donors. Nonetheless, the proponents of the
program remained firm in their assessment that this timeframe was appropriate
and realistic based on epidemiological facts (principally the then conceived
15 to 18 year lifespan of the adult worm).
36. Chbice 2f Technology. Part of the program's success can be attributed
to its conscientious pursuit of the best technology available for any task.
Consequently, aircraft have been used to apply larvicide and, more recently,
water level data have been transmitted using state of the art methods via
satellite enabling more accurate spraying levels so reducing environmental
risk. Computer modelling of onchocerciasis transmission has been developed
and is used in forecasting the progress of operations. Chromosome reading was
Introduced to identify species of the S. da!m-nos complex more efficiently and
the separation of vector and non-vector species. This reliance on the most
advanced tools available has helped maintain the cost-efficiency of
operations.
37. Contracting Out Highlv SReCialized Tasks. Another lesson which is of
broader interest concerns the contracting out of highly specialized
operations. Aerial spraying operations, the key element in the OCP strategy,
were contracted out to private companies uniquely qualified for the task. The
OCP accepted early on that it lacked the expertise to undertake such a large
and complex spraying effort involving a fleet of helicopters and sophisticated
spraying equipment. OCP did not make the mistake that many public agencies
have made -- of feeling obliged to undertake tasks considered critical to
achieving program objectives with in-house staff under their direct control.
It realized that it could bett.r maintain control and demand a higher level of
quality if this critical task were contracted out to a highiy specialized and
qualified firm.
38. ODerational esegarch. OCP, throughout its existence, has spent about
15% of its budget on operational research which has always been considered an
eoual partner in program implementation. By undertaking such operations-
related research, OCP has constantly improved its control technology and has
even generated new control tools. It has led to the creation of a special
drug development fund to seek a specific drug (a macrofilaricide suitable for
mass treatmert) which would interrupt onchocerciasis transmission. This
12
operational research has not only increased the program's efficiency and
reduced costs (for example, satellite transmission of data on accurate water
discharge) but has ensured survival of the program when critical technical
challenges arose (for example, rapid spread of resistance). Therefore,
emphasis on operational research has greatly facilitated the program's
adaptation to new situations.
39. New larvicides. as soon as they were approved by the Ecological Group,
were incorporated in the OCP arsenal; susceptibility testing became routine
for signalling when resistance was appearing, and a change of product was
called for; new techniques for identifying adults and larvae of the blackfly
species were immediately exploited to target the important vectors; improved
larvicide application equipment developed by the program was incorporated in
the bid documents of new aerial contracts; methods of distinguishing forest
from savannah types of onchocerciasis parasites are being sought to enable a
more effective demarcation of the program area; a mathematical model of
onchocerciasis has reached an advanced state of development enabling
predictions to be made of the long-term imract of both vector and chemotherapy
control and the risks of recrudescence.
40. Autonomy of the Program. The program was set up with a high degree of
autonomy from the Sponsoring Agencies. Specifically, while WHO is the
executing agency for the program, the OCP has never come under the direct
jurisdiction of the World Health Assembly or the WHO Executive Board. Its
special position has enabled it to overcome many of the administrative
procedures of WHO that might ha"e hampered implementation or brought it into
competition with other health priorities of WHO. A highly specialized program
such as OCP, is very different in nature from the horizontally organized
Primary Health Care programs which have been promoted by WHO over the last
decade. Also in this way WHO, itself a donor to the Special Fund, is
effectively a co-sponsor of the program and does not charge the usual 14%
agency administration fee which would normally apply.
41. The Program Director, having been delegated full responsibility for OCP
matters by the Director-General of WHO, reports directly to the JPC for
matters concerning the program. The program's autonomy has enabled it to
adjust operations quickly as circumstances dictate. The autonomy of the OCP
has proven especially important given the fact that it has been implemented
during a time when attention to tropical diseases has declined vis-a-vis other
important health concerns.
42. The program has been kept on track by its own in-built system of checks
and balances--which in the OCP's case provided by the EAC and the EG. These
bodies act as technical auditors and periodically provide objective
reassurance to supporters that continued commitment is justified; they also
help determine and legitimize any mid-course corrections that become
necessary. The EAC and EG produce detailed scientific documents which are a
staple of the annual JPC meetings. The credibility generated by this open
flow of information has helped maintain donor support. There is also the
financial auditing of the program which is carried out annually by both the
internal and external auditors of WHO, who have been very constructive and
laudatory in their comments or OCP. As fiscal agent, the Bank, on its own and
13
through the CSA also maintains a financial brief on the Program's operations
and expenditures on behalf of the JPC.
43. Goaoern oQf the XmorAm. Delegation of authority to those most
closely involved in the program has been crucial to assuring its ongoing
success. The CSA, which meets three to four times per year, has proven a
useful, persistent referee of the OCP since the beginning. The delegation of
responsibility for policy development and financial supervision to the GSA has
enabled crucial decisions to be taken between annual meetings of the JPC. The
JPC mandated the CSA to approve overruns on the budget of up to 10 in any one
year, to meet unforeseen expenditures. Such overruns were possible because of
the reserve held in the Trust Fund. The CSA supported the Bank in its efforts
to obtain approval for a prescribed contingency reserve held in the Trust Fund
to meet any emergency and to carry over the OCP from one financial phase to
the next. The CSA was also given responsibility for following socioeconomic
development of the area and, through the Bank, has been instrumental in
fielding a number of specific studies. Overall the CSA has played a major
role in ensuring that the program meets its objective by responding in a
timely fashion to changing operational and financial requirements and in
providing independent support when necessary.
44. Through the delegation of responsibility to him, the Program Director
has direct access to the CSA as well as to the donors and to the Participating
Country governments. At the national level, the Presidents of each of the
Participating Countries appointed National Onchocerciasis Committees to
resolve problems related to the program so that decisions can be made quickly
to avoid operational delays. The independence of the EAC and the EG has
enabled them to play an important role in influencing the governance of the
program and has prevented technical issues from being viewed politically, a
very necessary control in such a multicountry program.
45. Overall, this delegation of authority throughout the program has allowed
a continuity of governance by selecting individuals devoted to the program's
objectives and has ensured that a clear focus has been maintained year after
year. It has also permitted a necessary degree of flexibility that has made
it possible to respond in a timely and effective manner to strategic and
technological problems.
46. Medium-Term Ela=ning and SustainedDonor Cmmitment. In 1973, the PAG
mission report made it clear that success would depend on a minimum 20-year
financial commitment. Faced with the difficulty of sustaining donor support
over such a long period, the program was divided into a series of medium-term
planning phases. For each of these six year periods, the program prepared a
detailed plan of operations outlining the objectives to be reached during that
period, any modifications necessary and the estimated cost of the operations.
Based on these plans approved by the JPC, the donors adjusted the level of
their pledges for the period. At the start of each of the six-year financial
phases these revised pledges were incorporated in a new Trust Fund Agreement
signed by the donors. The Memorandum of Agreement which became an integral
part of the Trust Fund Agreement was signed by the Participating Governments.
These Fund Agreements have disallowed earmarking, thus permitting a high
degree of flexibility in financial management of the program. In this regard,
14
at its scheduled meetings, the JPC has the opportunity to review any
modifications detailed in annual budgets supported by Plans of Action
submitted for approval. These Agreements, based on approved Plans of
Operations, on the one hand tie the program into what it has to accomplish in
the six year period and, on the other, obligate the donors to an agreed level
of financial support for the same period and the Participating Countries to
their responsibilities. They have been crucial to ensuring the successful
evolution of the OCP and could provide a model for other programs involving
long term commitments and cooperation between a number of donors, agencies and
governments.
47. TransDarency - Infomtion Flow. The program has benefited greatly from
the transparency achieved by maintaining an unrestricted flow of information
about the program amongst all parties involved. It has also benefitted from
its own openness to inspection and review. The program has undergone annual
technical audits by the EAC which has reported its findings in frank annual
reports to the JPC. The OCP itself provides a detailed progress report to
each JPC meeting (both verbal and written) which covers technical, policy and
financial issues. The OCP openly welcomed the Independent Commission review
in 1981, the USAID Review Group review in 1985 and an Independent External
Review requested by the donors in 1990. This statutory reporting system is
augmented by regular visits to the donors by combined Bank/OCP missions and by
the OCP to the Participating Countrles. Throughout, difficulties have been
openly and candidly debated; this transparency has been greatly appreciated by
all parties concerned. This openness has played no small role in maintaining
the confidence of an ever-increasing group of donors and has helped ensure the
continual financing of the program. Confidence in the program has also
encouraged Participating Countries to maintain their annual 1.4% contribution
to OCP.
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